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2 BACKGROUND More than 25% of people with diabetes take insulin ADA and the European Association recently issued a consensus algorithm for management of type 2 diabetes Insulin identified as the most effective glucose-lowering agent Lower compliance with insulin regimens -associated with higher A1C levels and higher rates of hospital admission In a study using a Department of Veterans Affairs database, insulin use was 77% of prescribed amounts

4 OBJECTIVE The purpose of this study was to assess factors associated with patient frequency of intentionally skipping insulin injections and factors associated with this behavior, in a large sample of patients weighted to be representative of all adult diabetic patients in the U.S. who take insulin.

5 RESEARCH DESIGN AND METHODS Data were obtained through an Internet survey of U.S. Adults self-identified as taking insulin to treat type 1 or type 2 diabetes. Survey was conducted 13 June to 7 July 2008 by Harris Interactive, a contract research organization. Sample was drawn from the Harris Interactive Chronic Illness Panel. Patients were recruited by ,if they had diabetes and currently used a syringe or insulin pen to deliver insulin. Recruitment quota was 500 participants.

7 SAMPLE PROFILE The sample (n 502) was 55% male, 73% white, 11% Hispanic, 11% African American, and 5% other race/ethnicity Mean age of 55 years About 51% had attended college 38% were presently employed, and those not employed included 8% students and 8% disabled; the remainder were mostly retired or nonworking spouses Median annual income of the sample was about $35,000

9 Other relevant findings 32% reported as diagnosed with depression 77% - type 2 diabetes, and the rest with type 1 DM Diabetes for an average of almost 15 years Primary diabetes health care provider 61% PCP 28% endocrinologist 11% named another (non-physician) health care provider. 39% reported engaging in physical activity and 55% said they followed a healthy diet 70% took insulin using a syringe and 30% used a pen 56% changed their needle with each injection

10 Also.. Patients reported 2.7 injections a day (maximum of five recorded) 22% said they planned their daily activities around their insulin injections Similar proportions reported that insulin injections interfered with their lives 23% said insulin injections interfered with their eating/exercising schedule more than a little 25% said that insulin injections had a negative effect on one or more activity of daily living 22% reported they had to mentally prepare themselves before each injection 33% had some level of dread associated with taking their daily injections 21% reported often worrying about hypoglycemia Scores for pain and inflammation/ bruising were significantly higher than those for embarrassment, time needed, and ease of use, P 0.001

11 CONCLUSIONS Two aspects of patients treatment regimens were associated with increased insulin omission respondents who took more injections each day and those who did not follow a healthy diet were more likely to skip injections. Although respondents were self-selected and the sample was relatively small to determine the national prevalence of intentional omission of insulin doses Findings suggest that insulin omission is a substantial problem in the clinical care of diabetes. Peyrot et al. also recommend strategies for addressing these risk factors to prevent intentional insulin omission, which can inform clinical practice. Pain and embarrassment influence insulin omission suggests that alternate delivery systems such as an insulin pen system and better preparation for starting insulin may be useful

12 FACTORS INSULIN AND INJECTION-RELATED Study suggests that insulin omission is affected by the perceived burden of insulin therapy DEMOGRAPHIC & DISEASE FACTORS Respondents with higher household income, were less likely to skip insulin injections as easier access to medications and supplies, more access to diabetes education, higher health literacy no racial/ethnic differences in intentional insulin omission no overall association between age and intentional insulin injection omission among patients with type 1 type 2 diabetes, older respondents were less likely to skip insulin injections consistent with earlier studies Approx 10 15% of pts. with diabetes suffer from co-morbid major depression and diabetes non-adherence

13 Strengths & Limitations Strengths of the study include the large sample of diabetic patients drawn from a gen population and the sample was weighted to be nationally representative Study appears to be among the first to identify an association between socioeconomic status and insulin omission. No objective measure of insulin use (e.g., pharmacy records). Measure of insulin omission was very specific (i.e., skipping injections that respondents knew they should take), it is possible that some respondents included injections they did not skip intentionally, but rather simply forgot to take. Inclusions may be scheduled injections that were appropriately skipped because a meal was not eaten or blood glucose levels were very low.

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15 EDITORIAL National Health and Nutrition Examination Survey (NHANES) data showed 45% of patients with diabetes did not achieve glycemic targets of 7% Poor insulin adherence is a significant problem for health care delivery Patients may be more likely to adhere to their treatment if they believe it alleviates their diabetes symptoms Providers should address patients perceptions of the benefits of adhering to their treatment Many physicians and patients are resistant to initiate insulin therapy with higher rates of physicians delaying insulin therapy in the U.S. Addressing type 2 diabetic patients concerns about insulin early in the treatment may help minimize or prevent psychological insulin resistance & insulin omission

16 Other issues Connection between type 1 diabetes and eating disorders is of concern as associated with poor glycemic control, frequent episodes of DKA Restriction or omission of insulin may be an important symptom of a concurrent eating disorder Association of insulin omission and weight (DAWN study), concerns were associated with being female, less educated, diagnosis of type 2 diabetes Poorer insulin taking behaviors among African American and Hispanic patients compared with Caucasians (VA study) Peyrot et al. did not address important issues such as other selfcare behaviors, weight concerns, the impact of insulin delivery systems, and survey reliability and validity Not all insulin omission is motivated by weight issues, and suggest that the assessment of attitudes and beliefs about insulin is important to improve glycemia and diabetes self-management.

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